Submit a Claim

Claim Form

Contact Information

Please provide contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this Claim Form.

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Phone

Email

Settlement Benefits

All Class Members are eligible for Settlement Benefits but may only select one option, not both. The benefit options are:

Credit/Medical Monitoring, Lost Time, Ordinary Out-of-Pocket Losses, and/or Extraordinary Out-of-Pocket Losses: You may file a claim for real, documented Out-of-Pocket expenses, Extraordinary Losses, spent time responding to the Data Breach, and/or want to claim for Credit or Medical Monitoring; OR
Alternative Cash Payment: You may claim a one-time $40.00 cash payment.

Please select your Settlement Benefit.*

I would like to claim for Credit/Medical Monitoring, Lost Time, Ordinary Out-of-Pocket Losses and/or Extraordinary Out-of-Pocket Losses.

I would like to claim for the Alternative Cash Payment.

Attestation & Signature

By submitting this Claim Form, I swear and affirm on penalty of perjury that the information provided in this Claim Form, including supporting documentation, is true and correct to the best of my knowledge.

I understand that my claim is subject to verification and that I may be asked to provide supplemental information by the Settlement Administrator before my claim is considered complete and valid.

Signature

Date